© 2015 Medicare Rights Center January 2015 Medicare Benefits, Options, and Transitions Rules for People with ESRD Audio Portion: 1-866-740-1260 Web Portion:

Let’s Learn Medicare Medicare Benefits, Options, and Transitions Rules for People with ESRD

© 2015 Medicare Rights Center 7 Medicare Rights Center  The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through: Counseling and advocacy Educational programs Public policy initiatives

© 2015 Medicare Rights Center 8 National Council on Aging  This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging

© 2015 Medicare Rights Center 9 This training will cover  Parts of Medicare  Medicare eligibility and enrollment for people with End-Stage Renal Disease (ESRD) a lso known as kidney failure  Medicare coverage and costs for ESRD treatment  Other types of insurance and ESRD Medicare The 30-month coordination period  Coverage of immunosuppressant drugs after a kidney transplant  Medigap, Medicare Advantage plans, and Part D enrollment for people with ESRD  ESRD and the Health Insurance Marketplaces Note: Eligibility, enrollment and coordination of benefits work differently for ESRD Medicare than for Medicare based on age or disability. However, Medicare covers medical care for ESRD the same way as it covers care for people with Medicare due to age or disability.

© 2015 Medicare Rights Center 10 Parts of Medicare  Medicare benefits administered in three parts: Part A – Hospital/Inpatient Benefits Part B – Doctors/Outpatient Benefits Part D – Prescription Drug Benefit  What happened to Part C?  Medicare Advantage Plans (e.g., HMO, PPO) Way to get Parts A, B, and D through one private plan Administered by a private insurance company Not a separate benefit: everyone with Medicare Advantage still has Medicare

© 2015 Medicare Rights Center 12 Medicare eligibility based on ESRD  Someone is eligible for Medicare if: The person has End-Stage Renal Disease (ESRD), meaning that they have permanent kidney failure that requires dialysis or a kidney transplant; and The person, their spouse, or their parent has enough Medicare work history to qualify for Social Security or Railroad Retirement benefits (RRB)

© 2015 Medicare Rights Center 13 When Medicare begins with ESRD  The date when someone’s Medicare benefits begin depends on the type of treatment they receive Dialysis at a facilityHome dialysisKidney transplant Medicare begins after a three-month waiting period while receiving dialysis Coverage begins on the first day of the fourth month of dialysis Waiting period starts even if someone does not choose to sign up for Medicare No waiting period Medicare begins the same month as the home dialysis training program A doctor must expect that the beneficiary can finish the training program and continue home dialysis after it ends No waiting period Medicare begins the month someone goes into a Medicare- approved hospital for the transplant or the health care services needed before the transplant—as long as they get the transplant over the following two months

© 2015 Medicare Rights Center 15 End of Medicare coverage for ESRD  If an individual has Medicare only because of ESRD, Medicare coverage will end: 12 months after the month the individual stops dialysis treatments or 36 months after the month of a successful kidney transplant  If they have Medicare based on ESRD and then enroll in Medicare based on disability or age, Medicare enrollment continues  Note: If they had Medicare ESRD and it terminated, Medicare coverage will start again without a waiting period if they begin dialysis again or get another kidney transplant

© 2015 Medicare Rights Center 16 Medicare eligibility for children with ESRD  Children can qualify for Medicare: must have ESRD and have at least one parent who has sufficient Medicare work history  Children are: People who are unmarried and age 21 and younger People ages 22 to 25 in certain circumstances Adult dependent children

© 2015 Medicare Rights Center 17 Medicare, ESRD, and age  If an individual has Medicare based on age first, they do not need ESRD Medicare unless: They need an earlier Medicare start date  ESRD Medicare can be retroactive up to one year They did not enroll in Part B during their Initial Enrollment Period and want to enroll  They get another IEP to enroll in ESRD Medicare Part B without premium penalties They already have Part B but pay a premium penalty because they enrolled late  Enrolling in ESRD Medicare Part B will remove the premium penalty due to delayed Part B enrollment

© 2015 Medicare Rights Center 18 Medicare, ESRD, and disability  If an individual qualifies for Medicare based on disability first, they may want to enroll in ESRD Medicare if: They are still within their 24-month waiting period for Medicare based on disability  ESRD Medicare will start earlier than their Medicare for disability will They declined Part B during their Initial Enrollment Period and want to enroll  They get another IEP to enroll in ESRD Medicare Part B without premium penalties

© 2015 Medicare Rights Center 19 How to enroll in ESRD Medicare  Individual eligible for ESRD Medicare should enroll by calling Social Security (800-772-1213) or visiting local Social Security office  For incapacitated individual, a family member or other responsible party can also enroll for them  Eligible individual’s dialysis facility must complete and send a form to the Social Security Administration to confirm ESRD status and the type of treatment needed

© 2015 Medicare Rights Center 20 Medicare coverage of ESRD treatment Medicare covers:  Kidney transplants  Immunosuppressive drugs after a Medicare-covered kidney transplant As long as the person still qualifies for Medicare and has Part B  Hospital inpatient dialysis  Outpatient dialysis from a Medicare-certified hospital or free- standing dialysis facility  Home dialysis training, equipment, supplies, and medications from a dialysis facility Medication is only covered when overseen by a physician Note: Medicare covers all ESRD treatments the same way, regardless of whether someone has ESRD Medicare or Medicare due to age or disability.

© 2015 Medicare Rights Center ESRD Medicare costs Medicare Part A Costs for 2015 Premium Free for those with 10 years of Social Security work history $224 if you or your spouse worked and paid Medicare taxes for 7.5 to 10 years $407 if you or your spouse worked and paid Medicare taxes for fewer than 7.5 years Hospital deductible $1,260 for each benefit period Hospital copay $315 per day for days 61-90 each benefit period $630 per day for days 91-150 (these are 60 non-renewable lifetime reserve days) Skilled nursing facility copay $157 per day for days 21-100 each benefit period  Original Medicare costs apply for people with ESRD Medicare:

© 2015 Medicare Rights Center ESRD Medicare costs Note: coinsurance is sometimes called cost sharing Medicare Part B Costs for 2015 Annual deductible$147 Monthly premium$104.90 per month People with high incomes pay more for the monthly premium CoinsuranceMedicare pays 80% of Medicare-approved amount for a doctor’s service; you pay 20% coinsurance  Original Medicare costs apply for people with ESRD Medicare:

© 2015 Medicare Rights Center 24 What to consider before enrolling in Medicare  How employer coverage coordinates with ESRD Medicare  How Medicare covers immunosuppressive drugs after someone has a kidney transplant

© 2015 Medicare Rights Center 25 Employer insurance and Medicare  For people with ESRD Medicare, employer insurance can be any combination of: Active employer coverage from beneficiary or their spouse Retiree insurance Union coverage COBRA  Employer coverage is primary to Medicare for the first 30 months a person qualifies for Medicare based on ESRD The 30-month coordination period Note: Coordination of benefits works differently for ESRD Medicare than for Medicare based on age or disability, but Medicare covers medical care for ESRD the same way as it covers care for people with Medicare due to age or disability.

© 2015 Medicare Rights Center 26 The 30-month coordination period During 30-month coordination period Coordination period begins the month someone becomes eligible for Medicare Employer insurance pays primary to Medicare during this time Individual does not have to enroll in Medicare if they have other coverage You have until the end of the 30- month coordination period to enroll in Medicare After 30-month coordination period Medicare becomes primary payer Must be actively enrolled in Medicare This change will occur automatically, even if the individual never actively enrolled into Medicare

© 2015 Medicare Rights Center 27 Employer insurance and ESRD Medicare  If individual is enrolled in ESRD Medicare, it is the secondary payer during the 30-month coordination period This means that employer insurance pays first and Medicare pays second  This is true for both insurance based on current employment and retiree insurance  The 30-month coordination period starts when they first qualify to receive ESRD Medicare, even if they have not signed up for it yet  After the 30-month coordination period, ESRD Medicare pays primary to employer coverage This switch is automatic and happens even if someone never actively enrolls in ESRD Medicare

© 2015 Medicare Rights Center 28 Taking Medicare for those with employer coverage  If an individual has employer coverage, it may still be best to enroll in ESRD Medicare when they first qualify Most cost effective way to get care ESRD patients need a lot of medical care Even if employer coverage is primary to ESRD Medicare, the individual may still have deductibles, copays, and coinsurances  Medicare will pay second and could help pay these costs  Medicare will also place limits on the amount providers can charge If they need an organ transplant and have Medicare when they get the transplant, Part B will cover their immunosuppressant drugs  People should talk to their employer before deciding to delay ESRD Medicare coverage Ask how costs will compare if they have employer coverage alone versus employer coverage and Medicare

© 2015 Medicare Rights Center 29 Delaying Medicare for people with employer coverage  If a person decides to delay ESRD Medicare enrollment: Delay enrollment in both Part A and Part B This means they should not enroll in Part A and should decline Part B  If they defer enrollment in both Parts A and B, they can enroll in both parts at any time while they still have ESRD  If they enroll in Part A and decline Part B, they may have gaps in coverage and higher costs They will only be allowed to enroll in Part B during the General Enrollment Period (GEP) (January 1 – March 31 of each year) Premium penalty will apply for each 12-month period they delayed enrollment

© 2015 Medicare Rights Center 30 Delaying Medicare for people with employer coverage  To prevent a gap in coverage, individual should apply for ESRD Medicare Parts A and B a few months before 30- month coordination period ends Ask for Medicare to begin the month after their coordination period ends. Remember:  30-month coordination period begins the month a person becomes eligible for Medicare  After 30-month coordination period, Medicare pays first and employer insurance pays second  Once Medicare becomes primary, employer coverage can refuse to cover someone if they failed to enroll in Medicare If individual had kidney transplant, they should enroll in Medicare within one year of their transplant to make sure Medicare will cover immunosuppressive drugs

© 2015 Medicare Rights Center 32 Medigap policies for people with ESRD  Medigap policies (Medigaps, also known as Medicare supplemental insurance): sold by private insurance companies, used to pay the costs associated with Original Medicare  Many people with Original Medicare purchase a Medigap to help pay Parts A and B cost-sharing  Federal law does not require Medigap insurers to sell Medigaps to people with ESRD who are under age 65 States may have additional protections that allow someone with ESRD to purchase a Medigap policy

© 2015 Medicare Rights Center 33 ESRD and Medicare Advantage plans  Most people with ESRD cannot join a Medicare Advantage plan. Two exceptions: If individual has ESRD, can join a Special Needs Plan (SNP) that specifically accepts people with ESRD, if there is one in their area  SNP: type of MA plan that specifically serves members who have a particular need, such as a chronic illness If individual has employer health plan coverage through the same insurance company that offers a MA plan, can enroll in that company’s MA plan  If ESRD develops after individual joins a MA plan, plan cannot disenroll them If the plan leaves Medicare, individual has one-time Special Enrollment Period (SEP) to join another plan in their area

© 2015 Medicare Rights Center 34 Enrolling in a Part D plan with ESRD  Individuals with ESRD Medicare can enroll in a Part D plan as they would with any other type of Medicare eligibility  People with employer coverage should talk to their employers to see how Medicare Part D would coordinate  Many people with employer coverage may not need Part D They can delay Part D without penalty if they have creditable coverage and join a Part D plan within 63 days of losing that coverage  Before joining a Part D plan, beneficiaries should make sure it will not cause their employer coverage to end for them or their family  If they do not have employer coverage, they should take Medicare Part D to help cover all their drug costs

© 2015 Medicare Rights Center 35 Part D coverage of ESRD-related drugs  A Part D plan must cover individual’s immunosuppressant drugs if they do not qualify for Part B coverage for them All Part D formularies must include most all immunosuppressive drugs  Step therapy not allowed once individual is stabilized on immunosuppressant drug However, prior authorization can apply to verify that Part B won’t cover needed drugs even after individual is stabilized on them  Individuals should double check to make sure the drugs they need are covered with the fewest restrictions and that their plan includes their pharmacy as a preferred network pharmacy

© 2015 Medicare Rights Center 36 ESRD and low-income programs  Individuals with ESRD Medicare can qualify for low- income programs to help with Medicare costs, such as: Medicare Savings Programs (MSP) Extra Help Medicaid  If an individual qualifies, Medicaid can provide secondary coverage to Medicare If individual has Medicaid and then develops ESRD, they will likely have to enroll in Medicare  Contact local Department of Social Services or State Health Insurance Assistance Program (SHIP) for more information regarding these programs

© 2015 Medicare Rights Center 38 Medicare coverage of immunosuppressants  After an individual has a kidney transplant, they will need to take immunosuppressant drugs for the rest of their lives to prevent body from rejecting organ  Normally, immunosuppressants are covered under Part A at the time of a Medicare-covered transplant  For post-discharge patient, Part B covers immunosuppressive drugs if: Individual had Part A at the time of their transplant, and Individual continues to have Part B  If they qualify for Medicare on the basis of ESRD alone, Medicare will end 36 months after a successful transplant  Medicare will not cover drugs after coverage ends  If they qualify for Medicare on another basis (age or disability), Medicare will not end and will continue to cover their immunosuppressive drugs

© 2015 Medicare Rights Center 39 Medicare coverage of immunosuppressants  If individual did not have Medicare when they had a transplant, there are two ways to get coverage: Enroll retroactively in Part A if it is within a year of their transplant Get coverage under their Part D plan since they do not qualify for Part B coverage of their drugs

© 2015 Medicare Rights Center 41 Health Insurance Marketplaces  A way for people to shop for health insurance coverage  Also called Exchange or Insurance Exchange  Insurance purchased through the Marketplace = Qualified Health Plan (QHP) QHPs purchased through the Small Business Health Options Program (SHOP) = SHOP plans QHPs purchased by individuals through the Marketplace = QHPs  Marketplace operations vary by state

© 2015 Medicare Rights Center 42 ESRD and the Marketplaces  SHOP plans work with ESRD Medicare the same way that other employer coverage does  Anyone who has any part of Medicare already cannot purchase a QHP  Most people with Medicare are not eligible for tax credits to purchase QHPs  People with ESRD are eligible for tax credits if they have not yet enrolled in any part of Medicare  People with ESRD who have QHPs first can keep those plans after they’ve taken Medicare Can still qualify for premium tax credits if they are under age 65  People with ESRD can choose to not enroll into Medicare and take a QHP instead

© 2015 Medicare Rights Center 43 ESRD and the Marketplaces  What form(s) of insurance to choose depends on many factors: Medical costs Existing insurance (i.e. employer insurance) Coverage needs  If someone decides to forego ESRD Medicare and enroll in QHP, it is best practice to get written confirmation from the QHP that it will provide primary coverage  People with ESRD who are considering a QHP instead of or in addition to Medicare should do an analysis of QHP costs and coverage against their own needs  When someone with ESRD turns 65 or becomes eligible for Medicare due to a disability, they should enroll in Medicare

© 2015 Medicare Rights Center 44 For more information and help  Local State Health Insurance Assistance Program (SHIP) www.shiptacenter.org www.eldercare.gov  Social Security Administration 800-772-1213 www.ssa.gov  Medicare 800-MEDICARE (633-4227) www.medicare.gov  Medicare Rights Center 800-333-4114 www.medicareinteractive.org  National Council on Aging www.ncoa.org www.centerforbenefits.org www.mymedicarematters.org www.benefitscheckup.org

© 2015 Medicare Rights Center Medicare Interactive  Medicare Interactive www.medicareinteractive.org  Web-based compendium developed by Medicare Rights to be used as a counseling tool to help people with Medicare Easy to navigate Clear, simple language Answers to Medicare questions and questions about related topics, for example: “How do I choose between a Medicare private health plan (HMO, PPO or PFFS) and Original Medicare?” 1.5 million annual visits and growing 45

© 2015 Medicare Rights Center January 2015 Medicare Benefits, Options, and Transitions Rules for People with ESRD Audio Portion: 1-866-740-1260 Web Portion:

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© 2015 Medicare Rights Center January 2015 Medicare Benefits, Options, and Transitions Rules for People with ESRD Audio Portion: 1-866-740-1260 Web Portion:

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